Older adults, especially those who are poor, often do not receive effective medical treatment for their conditions.

Low-income elders frequendy have socio-economic stressors, low literacy, multiple chronic illnesses and limited access to healthcare. When these adults do access care, typically it is fragmented - lacking in continuity and coordination between various healthcare professionals and settings.

These factors contribute to the disproportionately high utilization of acute care services and healthcare costs in this growing population, and prompted the design of a new integrated primary care model called Geriatric Resources for Assessment and Care of Elders (GRACE), which has been shown effective in improving the quality and costeffectiveness of care for low-income elders in Indianapolis, Ind.

HIGH QUALITY, COST-NEUTRAL CARE

My colleagues and I at the Indiana University Center for Aging Research made a study of the GRACE model, which we reported upon in the Journal of the American Medical Association (298:2623-2633, 2007). We registered improved quality of care, better healdirelated quality of life and reduced emergency department visits for patients receiving two years of care within the GRACE program, compared to a control group receiving care as usual.

For the sickest patients, or for those at high risk of hospitalization, GRACE substantially reduced hospital admission rates. A recent cost analysis of the GRACE model, published in the Journal of the American Geriatrics Society (57:1420-1426, 2009), showed that due to reductions in hospital costs offsetting increases in chronic and preventive care costs (including the costs of the GRACE intervention), the program is cost-neutral for high-risk patients in the first two years.

During the third year, me GRACE model showed cost savings in high-risk patients, which stemmed from continued lower hospital utilization rates and hospital costs.

INNER WORKINGS OF GRACE

The GRACE model builds on lessons learned from prior efforts to improve the care of older adults through multidimensional assessment and interdisciplinary team care. The program aims to improve tiie longitudinal integration of geriatric and primary care services across the care continuum - integration diat increases the likelihood of elders receiving recommended care.

The GRACE model turns on die following elements:

* a nurse-practitioner and social worker team offer in-home assessment and care management that collaborates with and supports die primary care physician;

* a geriatrics interdisciplinary team, led by a geriatrician and including a pharmacist, mental health social worker and community-based services liaison, provide patient care planning;

* specific care protocols are used extensively for evaluation and management of common geriatric conditions;

* a Web-based care management tracking tool and an integrated electronic medical record; and

integrated affiliated geriatric care, mental healtii care, pharmacy, home healdicare and community services.

America's healdicare workforce and infrastructure are inadequate to meet the needs of die aging population; die GRACE model was designed to optimize the roles of primary care and geriatrics healthcare professionals. Two full-time equivalent (FTE) nurse-practitioners, two social workers with a 0.5 FTE administrative assistant and 0.1 FTE each of a geriatrician, pharmacist, mental health social worker and community-based services liaison are needed to provide GRACE to approximately 220 high-risk patients from one or more primary care physician practices.

Initially, the GRACE nurse-practitioner and social worker meet wim the patient's primary care physician to review, modify and prioritize the care plan, men collaborate with the physician on putting it into practice. The GRACE interdisciplinary team holds weekly meetings to ensure accountability for care plan implementation and to help avoid any barriers to care. …